Male Reproductive System Notes
Hypospadias
- abnormal opening of the urethra onto the ventral surface of the penis or scrotum
- this results from failure of fusion of the urethral folds
- a fibrous band (chordee) distal to it will cause ventral curvature of the erect penis
- there is often associated cryptochidism, ureterovesical reflux, inguinal hernia, and/or other developmental problems
Epispadias
- abnormal opening of the urethra on the dorsal surface of the penis
- actually a form of exstrophy of the urinary bladder; there is often associated separation of the pubic bones and inadequacy of the urinary sphincters; incontinence and bladder infections are usual
- less common than epispadias and more difficult to correct sugically
Phimosis
- present when the prepuce cannot be retracted over the corona
- may be congenital if the opening is too small
- more often due to poor hygeine, resulting in chronic infection
- such an infections is called balanoposthitis
- paraphimosis results when a tight foreskin is forcibly retracted, and edema of the glans prevents its replacement; this can quickly lead to acute urinary retention and even gangrene of the glans
Priapism
- a persistent, non-pleasurable erection
- most are due to obstruction of the deep dorsal veins of the penis
- causes include sickle-cell disease, leukemia, metastatic cancer, and trauma
Urethritis
- gonorrhea and NGU are important STDs
- Reiter's syndrome - the enigmatic triad of arthritis, conjunctivitis, and urethritis
- most pts are positive for HLA-B27
Peyronie's Disease
- proliferation of the dense fibrous tissue involving a portion of the fascia; this leads to curvature of an erection
- many pts require a penis prosthesis
Warts
- condyloma acuminata
- a papillary, keratinizing lesion caused by the sexually transmitted HPV (6); commonly occurs in the urethral meatus in men
- to spot HPV, wet the man's external genitalia with acetic acid and involved areas show white; it's now called androscopy
- condyloma latum
- groups of flat-topped lesions which may ooze serous fluid; caused by secondary syphilis; typically occur in skin folds
Cancer of the Penis
- almost all are variations of squamous cell carcinoma
- originates on glans and prepuce
- risk factors include phimosis, smegma, and balanoposthitis
- the strongest risk is infection with HPV-16
- males circumcised as infants almost never get cancer of the penis
- spreads to inguinal lymph nodes; five year survival is around 50% overall
Premalignant lesions of the Penis
- erythroplasia of Queyrat - a raised, velvety plaque on the uncircumcised glans or prepuce
- histologic study shows dysplasia of the squamous epithelium
- a minority of cases develop into squamous cell carcimona if not removed
- Bowen's disease
- carcinoma in situ of the skin, most often on the penis or scrotum in men
- some cases develop into invasive squamous cell carcinoma
- Bowenoid papulosis - multifocal carcinoma in situ, caused by HPV-16
- giant condyloma of Buscke-Lowenstein, or verrucous carcinoma - another HPV related, very ugly cauliflower like lesion; invasive cancer can breed here
Male Infertility
- spermatogenesis can be temporarily diminished or even stopped by a host of factors ranging from heavy drinking to anabolic steroids to alcoholism to bicycling
- obstruction of the sperm passages may be more amenable than the above to surgical help
Cryptochidism
- incomplete descent of the testis into the scrotal sac
- cryptorchid testes may be found anywhere along the normal route of descent
- the epididymis is likely to be malformed or at least elongated
- ectopic testes is less common; it may stray into the superficial inguinal region, penis, or femoral sheath
- failure of the testes to descend causes problems:
- the tubules will undergo atrophy and fibrosis, beginning in infancy
- there is an increased risk of torsion of the spermatic cord and gangrene of the testis
- the risk of germ cell cancer in undescended testes is 30X greater than normal
- most is idiopathic
- may be associated with diethyl-stilbesterol exposure
Epididymitis and Orchitis
- nonspecific infections of the contents of the scrotum are usually complications of the urinary tract infection, instrumentation, or prostate surgery
- gonorrhea - the infection often spreads to the epididymis, less often the testis
- mumps - orchitis is common in adolescents and adults
- may cause atrophy of the germinal epithelium and infertility; the Leydig cells are spared
- TB can cause granulomas involving the epididymis
- syphilis can have gummas involving the testis; may spread to the epididymis
Torsion of the Spermatic Cord
- twisting of the spermatic cord is likely to result in venous infarction and gangrene in a few hours; quite common in children and adolescents
- the involved testis is painful and elevated, ususallt twisted 540
- the underlying problem may be abnormal fixation of the testis or cryptochidism
- unilateral spermatic cord torsion can somehow damage the opposite testis
- a person can also suffer los of one testis by catching it in a hernia
Germ Cell Tumors
- cancer of the germinal epithelium
- among the commonest solid tumors of young men
- over 95% of these tumors are malignant germ cell tumors
- current thinking is that these cancers emphasize their common origin from germ cells:
- seminoma (40%)
- embryonal cell carcinoma (25%)
- choriocarcinoma (2%)
- yolk sac carcinoma
- teratocarcinoma (25%)
- all present as painless, non-tender masses of the testis
- risk factors are poorly understood, they include cryptochidism and intersex malformations
- seminoma
- cancer that closely resembles young spermatocytes
- tumor cells have fried egg appearance; arranged in masses separated by fibrous septa with a lymphocytic infiltrate, may have syncytiotrophoblast and/or granuloma formation
- chorionic gonadotrophin is a tumor marker for the 50% or so of seminomas that contain syncytiotrophoblast
- typically metastasize to the retroperitoneal lymph nodes and then to the lungs
- good response to radiation; five-year survival rate of 95% or better
- embryonal cell carcinoma
- a very primitive cancer that arises in the testis
- grossly grayish-white masses with hemorrhage and necrosis
- teratoma + embryonal cell carcinoma = teratocarcinoma
- hCG and alpha-ferroprotein are tumor markers
- tumors with an embryonal cell carcinoma component metastasize to the retroperitoneum and everywhere else
- the response to newer chemotherapy protocols is very good, with around 85% apparent cures even when metastatic disease is widespread
- choriocarcinoma
- the bloodiest tumor; solid areas may be hard to find
- the malignant cells resemble placenta, and the pathologist must identify cytotrophoblast and syncytiotrophoblast
- HCG levels are very elevated
- until recently, choriocarcinoma arising in the testis was always lethal
- teratomas
- cystic teratoma of testis is rare and is mostly composed of skin, hair, sebaceous glands, teeth
- solid teratomas are of two types:
- mature solid teratoma is benign, usually occurs in children
- immature solid teratoma is malignant, usually contains embryonal cell carcinoma or sometimes squamous cell carcinoma
- a tumor of germ cell origin may be mixed with any other tumor of germ cell origin
- any tumor of germ cell origin may metastasize as another histologic type of germ cell tumor
- lymphoma arises in the testes of older men with some frequency
- adenomatoid tumor is a benign nubbin derived from mesothelium
- germ cell tumors can and do arise in the retroperitoneum, mediastinum, and pineal "because they are midline structures"
Stromal Tumors
- Leydig cell tumors - occur at any age, are usually benign, can produce precocious puberty or gynecomastia
- the gross and microscopic appearances aretypical for endocrine tumors
Hydrocele
- fluid in the tunica vaginalis; usually idiopathic, a hydrocele may contain 100cc or more of serous fluid
- you can distinguish a hydrocele from a tumor mass by transilluminating it with a bright light in a dark room
- hematocele - blood in the tunica vaginalis
Varicocele
- variscosities of the pampiniform plexus, usually on the left side
- common in young men, may cause fertility problems by warming the testes
- spermatocele - a cystic lesion up to 1 cm or so in the area of the rete testis, filled with fluid and dead sperms
Prostatitis
- acute and chronic prostatitis are uncomfortable problems, and are common in men who catch sexually-transmitted urethritis or lower urinary tract infections
- e. coli is the most common agent
- in acute prostatitis the gland is exquisitely tender; gonorrhea is an important cause
- in chronic prostatitis the gland is somewhat tender and the prostatic fluid you express contain WBC's and grows bacteria
- prostatodynia is a stress-related pain syndrome in which there are no WBC's in the prostatic fluid
- granulomatous prostatitis may be due to TB or idiopathic
Prostatic Hyperplasia
- something that happens to most intact men over about age 50; 10% men will need surgery
- the increased tissue is nodular overgrowth of periurethral glands and stroma
- the hyperplasia most often involves the lateral and median lobes
- the posterior lobe is the most common site for the development of prostatic adenocarcinoma
- median lobe hyperplasia by itself produces a median bar, obstruction without an enlarged gland
- prostatic hyperplasia casuses many problems, though most pts are are asymptomatic
- frequency, difficulty starting and stopping urination, incontinence, dysuria, hernias, acute urinary retention
- hematuria, bladder hypertrophy and trabeculation, bladder diverticula, bladder stones, hydronephrosis, renal failure
- residual urine accumulates in an enlarged bladder behind the prostate gland
Prostate Cancer
- adenocarcinoma of the subcapsular glands
- the second most common cancer in men, and the third leading cancer killer of men
- a disease of men over 50
- majority arise in the posterior lobes
- the etiology is essentially unknown
- early castration prevents the development of adenocarcinoma
- probably no link to infection or prostatic hyperplasia, or lack of sexual activity
- industrial exposure to cadmium
- cancer of the prostate preents as a painless lump in the gland
- almost all are prostate type adenocarcinomas: to diagnose you need one of the following
- prominent nucleoli in large nuclei with marginated chromatin
- invasion
- obvious distortion of architecture
- most prostate cancers, even the ones that have metastasized, are fairly well-differentiated adenocarcinomas
- cancer of the prostate seldom causes problems unless it spreads:
- rectal exam is the most effective method of diagnosis
- prostate cancer is often indolent even when it has metastasized, but some prostate cancers are very aggressive
- prostate cancer typically metastasizes to the axial skeleton, eventually causing miserable bone pain
- serum acid phosphatase is a classic tumor marker for prostate cancer
- surgery and/or radiation are useful for localized disease; conventional chemotherapy is of limited usefulness in prostate cancer, but protocols do exist
- usually quite responsive to endocrine manipulations
- one new important agent is leuprolide, a GnRH agonist
- another is anti-androgen flutamide, which shrinks prostate cancer supposedly without causing impotence
- ketoconazole is also an anti-prostatic drug